Santos, June 7NIZ
r-rnrMIN O F Q,UEEN,,5BUTrY
PINE VIEW CEMETEM' AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 74 5.4-477
Funeral Director sin jetot-
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�f Cremation
s Cremation Star- Led -7 s- c) A, M .
Cremation Completed 10 It-It ,
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of:
-N
(Name) (Sex)
(Street) (City) (S te) (zip)
who died on 2 7 day of 20 �5
at (S�-c r?s iF+�) _ p a�w.
(Place) (Address)
Name and addressof nearest relative or name of person Authorizing cremation:
IL m Gt n�J _';:C �&� )1- 'V C)" --5 I 2
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has no pa maker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the cremation of the remains and to
direct the disposition of the cremated remains, that any personal possessions have either been removed
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any
and all claims and demands for loss or damages which may be made against them by reason of or
connected with the cremation of s ' mains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudu nt.
-W
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address))
Signed on this date: ) /-?7)6